venous thrombo-embolism policy name: policy … · 3.3.2 as part of the discharge plan, patients...

your hospitals, your health, our priority

Date(s) previous version(s) approved: (if known)

Version:1

Date :March 2010

DATE OF NEXT REVIEW: OCTOBER 2015

Manager responsible for review: N.B. This should be the Author’s line manager

MEDICAL DIRECTOR

POLICY NAME: VENOUS THROMBO-EMBOLISM Reducing the risk of venous thrombosis in patients admitted to hospital

POLICY REFERENCE: TW10/049

VERSION NUMBER : 2.1

APPROVING COMMITTEE: VENOUS THROMBO-EMBOLISM (VTE) COMMITTEE

DATE THIS VERSION APPROVED:

OCTOBER 2012

RATIFYING COMMITTEE:

PARC (Policy Approval and Ratification Committee)

DATE THIS VERSION RATIFIED:

NOVEMBER 2012

AMENDMENTS MADE TO THIS DOCUMENT

Amendment to title of document Amendment to 3.1.1 & 3.2.1

AUTHOR(S) (JOB TITLE)

CLINICAL LEAD/CRITICAL CARE OUTREACH AND HEAD OF RESEARCH & DEVELOPMENT

DIVISION/DIRECTORATE: CORPORATE

TRUST WIDE POLICY (YES/NO) YES

Links to other Strategies, Policies, SOP’s, etc.

Venous thrombo-embolism guidance, All Party Parliamentary Thrombosis Group, NICE Clinical Guideline 92, Patient Information – Thromboprophylaxis Medicine Management Policy

Venous Thrombo-Embolism (VTE) and TW10/049 Version No.2

Author(s) Clinical Lead Critical Care Outreach and Head of Research & Development Approved (VTE COMMITTEE 2015)

Next Review OCTOBER 2015)

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CONTENTS PAGE NO.

1 INTRODUCTION

2

2 POLICY STATEMENT

2

3 KEY PRINCIPLES

3

4 RESPONSIBILITIES

3

5

HUMAN RIGHTS ACT 6

6

EQUALITY & DIVERSITY 6

7

MONITORING AND REVIEW

6

8 ACCESSIBILITY STATEMENT 6

APPENDICES

1 References and further information 7

2 Glossary of Terms used 8

3 Terms of Reference 9

4 Audit Tool 11

5 Assessment Tool Flow Chart 13

6 Patient Leaflet 14

7 a) Anti embolism stockings assessment

b) Anti embolism care plan

15

8 Equality Impact Assessment Form 17

9 Monitoring & Review template 20




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1. INTRODUCTION: 1.1 VTE prevention has too long been overlooked as a priority and only now are we beginning to understand the challenge around better VTE metrics and related health economics issues. In 2005 the Health Select Committee estimated that there were around 25,000 deaths each year from VTE in hospitals in England and that the cost of treating the long-term disability caused by VTE was around £640 million a year. In 2007 there were 16,670 recorded deaths in England and Wales where pulmonary embolism and deep vein thrombosis (VTE) were mentioned on the death certificate (Office of National Statistics).

1.2 However, the overall death rate from VTE in hospital and the community is likely to be significantly higher since the condition is often clinically silent and deaths are not being identified due to a reduction in post-mortem examinations. Indeed, it has been estimated that fewer than 1 in 10 fatal pulmonary emboli are diagnosed before death. The emerging picture of death and acute and chronic disability (such as chronic venous insufficiency, venous leg ulcers and pulmonary hypertension) leaves no room for complacency when low-cost effective preventative treatments are available. 1.3 VTE prevention is, above all, about saving lives and reducing long term ill-health. This is a common and often avoidable circumstance – many of us committed to VTE prevention know of friends, relatives, colleagues and patients who have suffered a deep vein thrombosis or a pulmonary embolism. We have long known of safe, effective and straightforward methods of prevention and will continue to work towards widespread recognition that VTE prevention is one of the most important new patient safety issues and ensuring that the major opportunities offered by the new NHS arrangements outlined by Lord Darzi are fully exploited to improve the quality of patient care in England in this regard. Chief Medical Officer Chair of All-Party Parliamentary Thrombosis Group 2. POLICY STATEMENT 2.1 Venous Thromboembolism (VTE) management is a key component of VTE prevention and control. Mandatory risk assessment is key to reducing death and associated disease rates. 2.2 This policy represents NICE Guidance and recommendations from the All-Party Parliamentary Thrombosis Group, which, when implemented, will help reduce the risk to a patient of developing a VTE.

2.3 VTE prevention is a government priority. The national VTE prevention strategy, led by the Chief Medical Officer, has the potential to save many thousands of lives, each year in hospitals across the country. Wrightington, Wigan and Leigh NHS Foundation Trust is committed to implementing the department of health policy that all patients receive a risk assessment for VTE on admission to hospital and as a result receive timely and appropriate prophylaxis.

AT ALL TIMES, STAFF MUST TREAT PATIENTS WITH RESPECT AND UPHOLD THEIR RIGHT TO PRIVACY AND DIGNITY.




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3. KEY PRINCIPLES: 3.1 Assessing the risks of VTE and Bleeding.

3.1.1 All patients admitted to hospital will be assessed for VTE and bleeding risk on admission.

3.1.2 All patients will be re-assessed for risk of bleeding and VTE within 24 hours of admission and whenever the clinical situation changes to:

ensure that the methods of VTE prophylaxis being used are suitable ensure that VTE prophylaxis is being used correctly identify adverse events resulting from VTE prophylaxis (Appendix 5).

3.2 Reducing the risk of VTE

3.2.1 Patients at increased risk of VTE who have no contraindications, will be offered

pharmacological prophylaxis as soon as possible after their risk assessment has been completed.

3.2.2 VTE prophylaxis will be continued until the patient is no longer at increased risk of VTE.

3.3 Patient Information and Planning for discharge 3.3.1 Prior to commencing on VTE prophylaxis, patients and/or their families will be offered verbal and written information on:

the risks and possible consequences of VTE

the correct use of VTE prophylaxis and its possible side effects

how patients can help reduce their risk of developing a VTE.

3.3.2 As part of the discharge plan, patients and/or their families/carers will be provided with verbal and written information on:

the signs and symptoms of deep vein thrombosis (DVT) and pulmonary embolism (PE);

the correct and recommended duration of VTE prophylactic use a home (if patient is

discharged with prophylaxis;

the importance of seeking help and who to contact if they have any problems using prophylaxis;

the importance of seeking medical help and who to contact if VTE is suspected. 4. RESPONSIBILITIES 4.1 Responsibility of the Trust Board. 4.1.1 It is accepted that ultimate responsibilities lie with the Chief Executive and the Trust Board. 4.1.2 The Trust Board delegates authority for approving this policy to the Quality Executive Committee. 4.1.3 The Trust Board will ensure, through line management structures, that this policy is fully applied and consistently adhered to. The Medical Director is the Quality and Safety lead for Wrightington, Wigan and Leigh NHS Foundation Trust. . 4.1.4 The Trust Board will receive a monthly VTE compliance report as part of the performance report (quality and safety section).




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4.2 Responsibilities of the Medical Director 4.2.1 To ensure that monitoring data is presented to the Trust Board. 4.2.2 To be responsible for this Policy and for allocating responsibility for writing the appropriate procedures etc. 4.2.3 To ensure that this Policy is reviewed within its appropriate time frame and is then taken to

the Quality Executive Committee for approval. 4.2.4 To ensure that the current version of this policy is accessible to all staff via the policy library on Trust intranet. 4.3 Responsibilities of the VTE Committee 4.3.1 The responsibilities of the VTE Committee are set out in the Terms of References (Appendix 3). 4.4 Responsibility of /Divisional Medical Director/ Managers/Heads of Nursing 4.4.1 To ensure that all staff are fully aware of this policy and the accompanying procedure(s) which will be available via the policy library on the Trust intranet. 4.4.2 To ensure that all relevant clinical staff receive adequate training to implement VTE Management. 4.4.3 To ensure that all clinical staff work within the local Policy. 4.4.4 To take local decisions within the defined parameters of Trust Policies. 4.4.5 To ensure that compliance to this policy is monitored using the audit tool provided (Appendix 4).

4.5 Responsibility of all staff 4.5.1 All staff have a duty to read and work within current policies. 4.5.2 All staff should know how to gain access to the Policy Library if a member of staff identifies that any part of a policy is no longer relevant, they have a responsibility to inform both the person responsible for writing or reviewing the Policy and the Policy Management Co-ordinator. 4.5.3 Nursing staff to complete Anti Embolic Stockings assessment on admission and to repeat if required (Appendix 8a and b). 4.5.4 The VTE risk assessment shall be performed by the admitting doctor on admission and subsequently by a doctor within the team responsible for continuing care (Appendix 5). 4.5.5 To ensure that patients are provided with Trust approved Patient Information on VTE (Appendix 6). 4.5.6 Adverse drug reactions should be reported immediately as per the Medicine Management

policy. 4.5.7 All clinical incidents involving VTE management of inpatients should be reported via the Trust




5

Incident Reporting mechanism and a Root Cause Analysis (RCA) undertaken. Reportable incidents include failure to undertake a VTE risk assessment; failure to commence timely VTE prophylaxis; diagnosis of VTE event (PE/DVT) during hospital stay; suspected/confirmed death resulting for VTE.

4.5.8 Medical staff are required to report all suspected/confirmed VTE deaths to the Coroner. 4.6 Responsibilities of the Pharmacist 4.6.1 The Pharmacist will review and advise on prescribed VTE prophylaxis. 4.6.2 Pharmacist will deliver VTE training to FY1 and FY2 doctors. 4.7 Responsibility of the Bereavement officer 3.7.1 When a patient has died as a result of a suspected or confirmed VTE, the bereavement officer will provide support and guidance to medical staff on the necessary reporting requirements to the Coroner. 4.8 Responsibilities of the Stakeholders 4.8.1 All those involved in producing the document (policy, guideline, strategy etc) have a

responsibility to ensure that consultation has taken place with the appropriate stakeholders. 4.8.2 Anyone who is asked for comments or to make a contribution to the document has a responsibility to respond to the request within the identified time frame, even if it is only to confirm that they are satisfied with the document as it stands. 4.9 Responsibility of Policy Management Co-ordinator 4.9.1 To be responsible for publishing all Policies/Procedures/Guidelines/Associated Paperwork to the Intranet “Policy Library”, in line with the publications scheme. 4.9.2 To notify the appropriate committee three months before the review date of any Policy, which is due to expire. 4.9.3 To notify the author (or the Medical Director if the author has left the Trust) that the Policy is due to expire three months before the review date.

5.0 Reporting to external agencies

5.1 The Trust is required to notify the National Safety Agency (NPSA) via the Datix when a VTE event occurs. 5.1.2 All VTE events will be reported to the National Safety Agency (NPSA) via the Datix via Incident reporting System. 5.1.3 Serious Adverse Events (SAE/SUI) will be reported strategically using the Strategic Executive Information Systems (StEIS). 5.1.4 Medical Staff are required to report all suspected or confirmed deaths to the Coroner.




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5. HUMAN RIGHTS ACT: Implications of the Human Rights Act have been taken into account in the formulation of this policy and they have, where appropriate, been fully reflected in its wording.

6. EQUALITY & DIVERSITY: The Policy has been assessed against the Equality Impact Assessment Form from the Trust’s Equality Impact Assessment Guidance and, as far as we are aware, there is no impact on any Equality Target Group.

7. MONITORING AND REVIEW:

7.1 The processes contained within the policy (TW10/049) will be audited in line with the audit

monitoring template contained in Appendix 4. 7.2 The results of audits will be monitored by Divisional Governance Leads. 7.3 This policy will be reviewed in November 2014.

8. ACCESSIBILITY STATEMENT: This document can be made available in a range of alternative formats e.g. large print, Braille and audiocassette.

For more details, please contact the HR Department on 01942 77(3766) or email [email protected]

mailto:[email protected]




7

Appendix 1 References and further Information:

Nice Clinical Guideline 92 Venous Thromboembolism, Reducing the risk: Jan 2010 This guideline updates NICE clinical guideline 46 and replaces it. All-Parliamentary Thrombosis Group: Feb 2010. NHS Operating Framework 2010/11, VTE in the Quality Framework DOH Commissioning for Quality and innovation (CQUIN): an addendum to the 2008 policy guidance for 2010/11. Medicine Management Policy: Version 2, Nov 2008. Policy and Procedure for the Implementation of National Institute for Health and Clinical Excellence (NICE) Guidance: Version 7 March 2012. Policy and Procedure for the reporting of Near Miss, Adverse Events and Serious Untoward Incidents: Version 8, March 2012. Guidance on thromboprophylaxis is available at:

• Surgical patients – see Venous Thromboembolism: Reducing the Risk in Surgical Inpatients. National Institute for Health and Clinical Excellence http://www.nice.org.uk/nicemedia/pdf/VTEFullGuide.pdf

• Medical patients – see Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients. Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance

• Obstetric patients – the risk assessment is not intended for use in pregnant women. See Thromboprophylaxis during Pregnancy, Labour and after Vaginal Delivery (37)

January 2004. Royal College of Obstetricians and Gynaecologists.

http://www.rcog.org.uk/index.asp?PageID=53

http://www.nice.org.uk/nicemedia/pdf/VTEFullGuide.pdf

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance

http://www.rcog.org.uk/index.asp?PageID=53




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Appendix 2 Glossary of Terms (relevant to Policy)

BMI: body mass index Dabigatran: dabigatran etexilate DVT: deep vein thrombosis Fondaparinux: fondaparinux sodium HRT: hormone replacement therapy INR: international normalised ratio (standardised laboratory measure of blood coagulation) LMWH: low molecular weight heparin PE: pulmonary embolism UFH: unfractionated heparin VTE: venous thrombo-embolism Definitions Major bleeding: a bleeding event that results in one or more of the following: – death – a decrease in haemoglobin concentration of ≥ 2 g/dl – transfusion of ≥ 2 units of blood – bleeding into a retroperitoneal, intracranial or intraocular site

– a serious or life-threatening clinical event – a surgical or medical intervention

Renal failure: estimated glomerular filtration rate (eGFR) < 30 ml/min/1.73 m2 Significantly reduced mobility:

– bedbound, – unable to walk unaided or – likely to spend a substantial proportion of the day in bed or in a chair




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Appendix 3

Venous Thrombo-Embolism (VTE) Committee

Terms of Reference

1.0 The VTE Committee will report to the Quality Executive Committee (QEC) 2.0 Major goals 2.1 The following key targets will be achieved:

2.1.1. Support and enable the implementation of the DOH VTE strategy in accordance with the Governance Framework

2.1.2. Promote educational initiatives to aid the understanding of the national VTE strategy

2.1.3 Significantly increase the compliance of the Trust by ensuring that all patients’ admitted to hospital receive a VTE Risk Assessment and if required, are prescribed and provided with the relevant prophylactic treatment

2.1.4 Develop Divisional Standard Operational Procedures (SOP’S) in consultation with the relevant interested parties

2.1.5 To encourage all specialties to promote the VTE Initiative

3.0 Key strategies 3.1 The following strategies will be pursued by the VTE Committee:

3.1.1. Develop a VTE infrastructure across Wrightington, Wigan and Leigh NHS Foundation Trust

3.1.2 Strengthen the provision of information to Trust staff on VTE related activity

3.1.3. To generate ideas and provide the impetus for the management of VTE throughout the

Trust.

3.1.4. To establish and implement systems to evaluate and manage the risk of VTE. The systems should be determined in consultation with all senior Clinical personnel working within the Trust.

3.1.5. To monitor external factors likely to influence the Trusts VTE priorities particularly with

respect to the potential sources of external funding. These will include Government and NHS initiatives.

3.1.6. To develop, maintain and scrutinise a VTE Root Cause Analysis (RCA) matrix which

will enable the VTE committee to provide assurance to the Quality Improvement Committee that lessons are being learned.

3.1.7. To provide an annual report for presentation to the Quality Improvement Committee by

the end of June each year




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3.1.8. To review regularly, links with outside institutions.

3.1.9. The VTE Committee can form sub committees to perform specific actions.

3.1.10. The VTE Committee will meet with a frequency determined by itself,

4.0 VTE Committee

4.1. Structure 4.1.1 Committee membership to include:

- VTE Chair - VTE Deputy Chair - Broad panel of Consultants from all specialities - Nurse Representative - Radiographer - Physiotherapist - Pharmacist - Trust Board Executive - Lay member

5.0 Responsibilities of the Committee

5.1 To advise and support the strategic implementation of VTE Policy 5.2 Compliance - To review WWL performance and advise on how this can be optimised 5.3 To review and monitor RCA investigation 5.4 To assist in improving the standard of VTE care delivery on all admissions 5.5 To be aware of and fully understand the QUIP agenda 5.6 Review and lead on RCA investigations

Terms of Reference agreed by VTE Committee Signed:……Medical Director……………………………………Nominated Chair Date:……9th October 2012




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Audit Tool Appendix 4

Thromboprophylaxis Audit

Patient details

Patient initials DOB

Gender Age in years

Admission information

Thrombosis risk assessed and documented

Speciality responsible

Other: please specify

Initially admitted from

Principal diagnosis


Expected duration of admission

Types of anti-coagulant given

Thromboprophylaxis Rx If no why?

TEDS

LMWH Low prophylactic dose

LMWH high prophylactic dose

LMWH ACS dose

LMWH VTE treatment dose

UFH 5,000IU bd

Aspirin for prophylaxis (e.g. 300mg)

Aspirin for CHD (e.g.75mg)

Warfarin

Other




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Does the patient have any contraindication to medical thromboprophylaxis?

Bleeding (active & uncontrollable) Spinal tap or epidural within 12hrs

Hypersensitivity to UFH or LMWH Haemorrhagic stroke

Heparin induced thrombocytopenia

Coagulopathy

Other If other please specify:

Venous Thromboembolic risk factors

History of VTE Pregnancy / postpartum

History of malignancy Nephrotic syndrome

Age >60 years Dehydration

Prolonged immobility Thrombophilia

Varicose veins Thrombocytosis

Obesity

Hormone therapy

Duration of thromboprophylaxis treatment

Expected duration of prophylaxis treatment (start to discharge)




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Appendix 5

Process for assessment of risk of VTE VTE assessment flow chart

Decision to admit

Risk assessment completed (Exceptions on risk assessment)

Is the patient at risk of developing a VTE?

Yes No

Commence prophylaxis treatment as per

prescription If not given for any reason

this must be documented in the case notes

Review within 24hrs

If VTE is suspected

Diagnostics to confirm

No Yes

Treatment as per policy

Continue prophylaxis




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Appendix 6 Patient Leaflet

http://www.wwl.nhs.uk/Library/All_New_PI_Docs/Audio_Leaflets/General/Blood_Clot_VTE/FT2_Stop_the_Clot.pdf

http://www.wwl.nhs.uk/Library/All_New_PI_Docs/Audio_Leaflets/General/Blood_Clot_VTE/FT2_Stop_the_Clot.pdf




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Appendix 7a

ASSESSMENT FOR THE USE OF ANTI EMBOLISM STOCKINGS FOR ADULT

PATIENTS ON ALL WARDS WHO HAVE REDUCED MOBILITY,

UNDERGOING SURGICAL INTERVENTION OR HAVE CLOTTING

DISORDERS

Name ……………………….. Ward ……………………… Hosp……..…………………

Problem: The patient is at risk of developing a deep vein thrombosis

Expected Outcome: Prevention of deep vein thrombosis

Date/

Time Assessment

Yes/No

Signature

Do not apply anti-embolism stockings to patients with:

Suspected or proven peripheral arterial disease

Absent/weak foot pulses

Slow capillary filling (pinched nail bed that takes

more than three seconds to return to normal

colour.)

Trophic skin changes (cold, pale, shiny, hairless

leg)

History of intermittent claudication or rest pain

Leg oedema or pulmonary oedema from congestive

cardiac failure (CCF)

Peripheral arterial bypass grafting

Peripheral neuropathy or other causes of sensory

impairment

Location condition in which stockings may cause

damage, such as fragile ‘tissue paper’ skin, dermatitis,

gangrene or recent skin graft.

Cardiac failure

Severe leg oedema or pulmonary oedema from

congestive hear failure

Major limb deformity preventing correct fit

Acute Stroke

Known allergies to the components/materials of the

stockings

Heel pressure ulcers

Diabetes

Cellulitis

Venous ulcers or wounds.

Patient is deemed suitable for the application of anti embolism

stockings

Yes No

Signature




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ixb Appendix 7b

CARE PLAN FOR THE USE OF ANTI EMBOLISM STOCKINGS (to be completed for each patient wearing anti embolism stockings

1.

Patients has been informed of the recommendation to wear graduated support stockings

(GSS) and given an information leaflet.

2.

Date/time Signature

3.

4. Measure legs in accordance with the manufacturer’s instruction:

5.

Ankle: cm; Calf: cm

Knee-heel: cm. Thigh-heel cm

Size applied:

(please fix fitting label from packet here)

6.

7. If oedema or postoperative swelling develops, reassess for continued use.

Encourage patients to wear the stockings day and night from admission until they no

longer have significantly reduced mobility.

At the beginning of each shift nurses will check to ensure GSS are in place and fitted

appropriately i.e. no wrinkles (which can act as a tourniquet and increase the risk of

DVT).

Graduated support stockings will be worn for 23.5 hours per day; during the half hour

when they are removed the skin will be re-examined for discolouration of skin or

pressure damage

Remove stocking if:

Blistering or discolouration of skin, particularly over heels and bony

prominences

Patient has pain or discomfort.

Show patients how to use anti-embolism stockings correctly and ensure they understand

that this will reduce their risk of developing VTE.

Patients will be discharged with anti-embolism stockings unless medically contra-

indicated (NICE 2011)

Patient will receive patient information leaflet and verbal advice prior to discharge.




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Appendix 8

EQUALITY IMPACT ASSESSMENT FORM – STAGE 1

INITIAL ASSESSMENT (PART 1)

FOR USE WITH POLICY’S AND SOP’S

Division: Corporate

Department: All

Title of Person(s) Completing Form

C Birchall/M Leyland New or Existing Policy?

Existing

Title of Policy being assessed:

Venous Thromboembolism prophylaxis

Implementation Date (Policy)

September 2012

What is the main purpose (aims / objectives) of this policy?

Reducing risk of venous thromboembolism in patients admitted to hospital

Will patients, carers, the public or staff be affected by this policy? Please delete as appropriate.

Patients Yes

Carers Yes

Public Yes

Staff Yes

If staff, how many individuals / Which Groups of Staff are likely to be affected? All staff

Have patients, carers, the public or staff been involved in the development of this policy? Please delete as appropriate.

Patients No

Carers No

Public No

Staff Yes

If yes, who have you involved and how have they been involved: Consultation

What consultation method(s) did you use?

focus groups, face-to-face meetings, awareness sessions

How are any changes / amendments to the policy communicated?

New policy will be launched by Meetings / Focus / Email etc.

QUESTIONS YOU MUST CONSIDER when completing the following Equality Impact Assessment Table:

Are there any barriers which could impact on how different groups might benefit from this policy?

Does this policy promote the same choices for different groups as everybody else?

Could any of the following group’s experience of this policy be different?

Does this policy address the needs and potential barriers of these groups?




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` EQUALITY IMPACT ASSESSMENT TABLE – POLICIES (PART 2)

Equality Group

Positive Impact

High Low None

Negative Impact

High Low None

Reason/Comments for

Positive Impact

(Why it could benefit any / all of the Equality Groups)

Reason/Comments for

Negative Impact

(Why it could disadvantage any / all of the Equality

Groups)

Resource

Implication

Yes / No

Men

High

None

Reduce harm and improve patient safety

Women High

None


Younger People (17-

25) and Children

High

None


Older People (60+)

High

None


Race or Ethnicity

High

None


Learning Difficulties

High

None


Hearing Impairment

High

None


Visual Impairment

High

None


Physical Disability

High

None


Mental Health Need

High

None


Gay/Lesbian/Bisexual

High

None


Transgender

High

None Reduce harm and improve patient safety

Faith Groups (specify)

High

None


Marriage & Civil

Partnership

High


Pregnancy & Maternity

High


Carers

High

None


Other Group (specify)

High


Applies to ALL Groups

High


High: There is significant evidence of a negative impact or potential for a negative impact. Low: Likely to have a minimal impact / There is little evidence to suggest a negative impact. None: A Policy with neither a positive nor a negative impact on any group or groups of people, compared to others.




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INITIAL ASSESSMENT (PART 3)

(a) In relation to each group, are there any areas where you are unsure about the impact and more

information is needed?

Special circumstances included

(b) How are you going to gather this information?

Audit

(c) Following completion of the Stage 1 Assessment, is Stage 2 (a Full Assessment) necessary? Have you identified any issues that you consider could have an adverse (negative) impact on people from the

following Equality Groups?

(Please delete YES/NO as appropriate)

Age (Younger People (17-25) and Children / Older People (60+) NO

Gender (Men / Women) NO

Race NO

Disability (Learning Difficulties / Hearing Impairment / Visual Impairment / Physical Disability / Mental Illness)

NO

Religion / Belief NO

Sexual Orientation (Gay / Lesbian / Bisexual) NO

Gender Re-assignment NO

Marriage & Civil Partnership NO

Pregnancy & Maternity NO

Carer NO

Other NO

Any other comments

Assessment completed by (Job Title) : Clinical Lead Critical Care Outreach Date Completed : May 2012

If ‘NO IMPACT’ is identified Action: No further documentation is required. If ‘YES IMPACT’ is identified Action: Full Equality Impact Assessment Stage 2 form must be completed. Refer to link below: http://intranet/Departments/Equality_Diversity/Equality_Impact_Assessment_Guidance.asp

PLEASE RETURN A COPY OF THE COMPLETED ASSESSMENT FORM (STAGES 1, 2 & 3) VIA E-MAIL TO:

DEBBIE JONES, EQUALITY AND DIVERSITY PROJECT LEAD (for Service related policies) [email protected] EMMA WOOD, EQUALITY AND DIVERSITY PROJECT LEAD (for HR / Staffing related policies) [email protected]

http://intranet/Departments/Equality_Diversity/Equality_Impact_Assessment_Guidance.asp



your hospitals, your health, our priority

Appendix 9

POLICY/SOP MONITORING AND REVIEW ARRANGEMENTS

NAME OF POLICY:

Para Audit / Monitoring requirement Method of Audit / Monitoring Responsible person

Frequency of Audit

Monitoring committee

Evidence Location

Audit of compliance to risk assessment

Paper based collection of patient prescription charts

Ward Sister Monthly VTE committee

venous thrombo-embolism policy name: policy … · 3.3.2 as part of the discharge plan, patients...

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